Phineas Gage
Phineas P. Gage (July 9?, 1823 – May 21, 1860) was a railroad construction foreman now remembered for his incredible survival of an accident in which a large iron rod was driven completely through his head, destroying one or both of his brain's frontal lobes, and for that injury's reported effects on his personality and behavior—effects said to be so profound that friends saw him as "no longer Gage." Long called "the American Crowbar Case"—once termed "the case which more than all others is calculated to excite our wonder, impair the value of prognosis, and even to subvert our physiological doctrines"Campbell, H.F. (1851) "Injuries of the Cranium—Trepanning". Ohio Med. & Surg. J. 4(1):31–5 (crediting the Southern Med. & Surg. J., unknown date)—Phineas Gage influenced 19th-century thinking about the brain and the localization of its functions,Barker (1995). and was perhaps the first case suggesting that damage to specific regions of the brain might affect personality and behavior. Gage is a fixture in the curricula of neurology, psychology and related disciplines, and is frequently mentioned in books and academic papers; he also has a minor place in popular culture. Relative to this celebrity, the body of known fact about the case is remarkably small, and this has allowed it to be cited, historically, in support of distinct theories of the brain and mind wholly contradictory to one another. A survey of published accounts has found that even modern scientific presentations are usually exaggerated and distorted in significant ways, contradicting the established facts. A daguerreotype portrait of Gage—"handsome...well dressed and confident, even proud," and holding the tamping iron which injured him—was identified in 2009 (see right). One researcher points to it as consistent with a "social recovery" hypothesis, under which Gage's most serious mental changes may have existed for only a limited time after the accident, so that in later life he was far more functional, and socially far better adapted, than has been thought. Gage's accident , p.27]] On September 13, 1848, 25-year-old Gage was foreman of a work gang blasting rock while preparing the roadbed for the Rutland & Burlington Railroad outside the town of Cavendish, Vermont. After a hole was "drilled" into a body of rock (via a laborious process which today might best be thought of as "chiseling")Macmillan (2000), p.25 one of Gage's duties was to add blasting powder, a fuse, and sand, then compact ("tamp down") the charge using a large iron rod. Possibly because the sand was omitted, around 4:30 PM: Nineteenth-century references to Gage as "the American Crowbar Case" may mislead some readers. For Americans of the time a crowbar did not have the bend or claw sometimes associated with that term today. Gage's iron was something like a javelin, "round and rendered comparatively smooth by use": Harlow (1848), p.331 Weighing 13–1/4 lb (6 kg), this "abrupt and intrusive visitor" Bibliographical notices. Recovery from the Passage of an Iron Bar through the Head. By John M. Harlow, M.D., of Worburn. (1869). Boston Medical and Surgical Journal, March 18, 1869. 3(7)n.s.:116–117 was said to have landed some 80 feet (25 m) away. Amazingly, Gage spoke within a few minutes, walked with little or no assistance, and sat upright in a cart for the 3/4-mile ride to his lodgings in town. The first physician to arrive was Dr. Edward H. Williams: Dr. John Martyn Harlow took charge of the case about an hour later: Despite Harlow's skillful care,Barker (1995), pp.679–80; Macmillan (2000), pp.12,60–62; Macmillan (2008), p.828–9 Gage's recuperation was long and difficult. A "fungal" infection left him semi-comatose from September 23 to October 3, "seldom speaking unless spoken to, and then answering only in monosyllables." On October 7 he took his first step. On October 20 Harlow described his patient as "very childish," and while the doctor was absent for a week, Gage was "in the street every day except Sunday," his desire to return to his family in New Hampshire being "uncontrollable by his friends." He soon developed a fever, but by mid-November he was "feeling better in every respect...walking about the house again; says he feels no pain in the head." Harlow's final prognosis at the time was that Gage "appears to be in a way of recovering, if he can be controlled." Harlow (1848), p.393. ]] Subsequent life and travels Except for loss of vision (and ptosis) of the left eye, and a large scar on the forehead, Gage's physical recovery seems to have been essentially complete by April 1849.Harlow (1849). Harlow says that Gage, unable to return to his railroad work, was for a time an attraction at P.T. Barnum's American Museum in New York City (the curious paying to see, presumably, both Gage and the instrument that injured him) although there is no independent confirmation of this. Recently however, evidence has surfaced supporting Harlow's statement that Gage made public appearances in "the larger New England towns." Harlow (1868), p.415. On Gage's job-loss and public appearances, see more below. Gage later worked in a livery stable in New Hampshire, and then for some years in Chile as a coach driver. After his health began to fail around 1859, he left Chile for San Francisco, where he recovered under the care of his mother and sister (who had relocated there from New Hampshire around the time he went to Chile). For the next few months he did farm work in Santa Clara. Death and subsequent travels In February 1860, Gage had the first in a series of increasingly severe convulsions, and he died in or near San Francisco on May 21 — just under twelve years after his accident. He was buried in San Francisco's Lone Mountain Cemetery. In 1866, Harlow somehow learned where Phineas had been and began a correspondence with his family, still in San Francisco. At his request they opened his patient's grave long enough to remove the skull, which was delivered to Harlow back in New England. About a year after the accident, Gage had allowed the tamping iron to be placed in Harvard Medical School's Warren Anatomical Museum, but he later reclaimed it and (according to Harlow) made what he called "my iron" his "constant companion during the remainder of his life"; now it accompanied the skull on its journey to Harlow. After studying them for his second (1868) paper, Harlow redeposited the iron, now with Gage's skull, in the Warren Museum, where they remain on display today. The iron bears this inscription: Text of inscription from The date given for the accident is of course wrong, and Phinehas is not how Gage spelled his first name (figure, Macmillan 2008 p.839); but the standardization of spelling may not have been well enough established at the time for this to be considered an error, strictly speaking. P. Gage at Cavendish, Vermont, Sept. 14, 1848. He fully recovered from the injury & deposited this bar in the Museum of the Medical College of Harvard University. Phinehas P. Gage Lebanon Grafton Cy N-H Jan 6 1850.}} Much later, Gage's headless remains were moved to Cypress Lawn Cemetery as part of a mandated relocation of San Francisco's dead to new resting places outside city limits.Macmillan (2000), pp.119-120 Brain damage and mental changes Significant injury to the brain is often fatal, but as noted earlier the iron's 1/4-inch leading point may have reduced its destructiveness, and apparently all important blood vessels were spared. Nonetheless, the brain tissue destroyed must have been substantial (considering not only the initial trauma but the subsequent infection as well) though debate as to whether this was in both frontal lobes, or primarily the left, began with the earliest papers by physicians who had examined Gage.Harlow (1848); Bigelow (1850); Harlow (1868). See also: *Dupuy, E. (1877) A critical review of the prevailing theories concerning the physiology and the pathology of the brain: localisation of functions, and mode of production of symptoms. Part II. ''Medical Times and Gazette v.II pp.356–8. *Ferrier, D. (1878) The Goulstonian lectures of the localisation of cerebral disease. Lecture I (concluded). Br. Med. J., 1(900):443–7 *Bramwell, B. (1888) The Process of Compensation and some of its Bearings on Prognosis and Treatment Br. Med. J. 1(1425):835–840 doi: 10.1136/bmj.1.1425.835 *Cobb, S. (1940) Review of neuropsychiatry for 1940. Arch. Internal Medicine. 66:1341–54 *Cobb, S. (1943) Borderlands of psychiatry. Harvard University Press. *Tyler, K.L. and Tyler, H.R. (1982) A "Yankee Invention": the celebrated American crowbar case. Neurology 32:A191. A 1994 CT modelling study by Hanna Damásio and colleagues suggests bilateral damage to the medial frontal lobes,H. Damasio (1994) but a 2004 study by Ratiu and colleagues, based on a CT scan of the actual skull, Ratiu (2004), and see also Macmillan. (2008) tends to confirm Harlow's view that the damage was confined to the left frontal lobe. Neurologist Antonio Damasio uses Gage to illustrate a hypothesized link between the frontal lobes, emotion and practical decision-making. But any theory that looks to Gage for support faces the difficulty that the nature, extent, and duration of the injury's effects on his mental state are very uncertain. In fact, little is known about what Phineas was like either before or after his injury (almost none of it first-hand),Macmillan (2000), pp.89 the mental changes described after his death were much more dramatic than anything reported while he was alive, and even those descriptions which seem credible do not specify the period of his post-accident life to which they are meant to apply. In his 1848 report, as Gage was just completing his physical recovery, Harlow had only hinted at possible psychological symptoms: "The mental manifestations of the patient, I leave to a future communication. I think the case...is exceedingly interesting to the enlightened physiologist and intellectual philosopher." And after observing Gage for several weeks, Henry Jacob Bigelow, Professor of Surgery at Harvard, wrote in 1850 that Gage was "quite recovered in faculties of body and mind." Bigelow (1850), p.14. (After noting dryly that, "The leading feature of this case is its improbability," Bigelow emphasized that although "at first wholly skeptical, I have been personally convinced," terming the case "unparalled in the annals of surgery." Bigelow (1850), pp.13,19. Bigelow's stature largely ended scoffing about Gage among physicians in general — one of whom, Harlow later wrote, had dismissed the matter as a "Yankee invention.") Harlow (1868), p.344. It was not until his 1868 report that Harlow gave particulars of the mental changes found today (often in exaggerated or distorted form — see below) in most textbooks. In memorable language, he now described the pre-accident Gage as having been hard-working, responsible, and "a great favorite" with the men in his charge, his employers having regarded him as "the most efficient and capable foreman in their employ." But these same employers, after Gage's accident, "considered the change in his mind so marked that they could not give him his place again": It is difficult to find anything written about Gage which does not draw on this passage, particularly its existentially troubling conclusion. Yet it is unknown on just what exactly Harlow based this description, set down twenty years after his treatment of Phineas: *He may have been working from his own notes made in the months after the accident — which would not apply to the patient's long-term outcome. *He may have been working from his own (or Gage's acquaintances', or Gage's mother's) recollections of Gage prior to Gage's circa-1852 departure for Chile — also not applicable to the long-term outcome, nor perhaps fully trustworthy given the intervening decades. *Or he may have been drawing on Hannah Gage's intermittent observations of her son during his nine months in California just before he died — these observations not recounted to Harlow until six or seven years later. *The raw material for Harlow's description may even have come to him via some still-more-indirect path, such as by mother Gage recollecting for Harlow, in 1868, statements made to her by others about their observations of Phineas during his time away from her on his New England travels (between his physical recovery and his departure for Chile). Of the handful of available primary sources on Gage, Harlow's 1868 presentation is by far the most informative, and there is no reason to doubt its general reliability. However, it is difficult to match the long list of facets he describes in Gage's behavior (which vary greatly in their implied level of functional impairment) to the period of Gage's life during which each was present, and this complicates reconstruciton of what Gage was like during those various periods.Macmillan (2008), p.839 Distortion and misuse of case All modern authors agree that Gage displayed some kind of change in behavior after his accident, though they frequently describe these changes in terms well beyond anything given by Harlow. Psychologist Malcolm Macmillan, in his book An Odd Kind of Fame: Stories of Phineas Gage,Macmillan (2000), esp. chs. 13–14. surveys scores of accounts of the case (both scientific and popular), finding that they are varying and inconsistent, typically poorly supported by the evidence, and often in direct contradiction to it. These accounts commonly ascribe to Gage drunkenness, braggadocio," "a vainglorious tendency to show off his wound," an "utter lack of foresight," inability or refusal to hold a job, and much more — none of these mentioned by Harlow nor by anyone else claiming actual knowledge of Gage's life.According to Macmillan (2008, p.830) these are Harlow (1848 and 1868), Bigelow (1850) and * Jackson, J.B.S. (1849) Medical Cases (Vol 4, Case 1777) Countway Library (Harvard University) Mss., H MS b 72.4 (quoted at Macmillan 2000, p.93) * Jackson, J.B.S. (1870) A Descriptive Catalog of the Warren Anatomical Museum Nos. 949–51, 3106 (republished in Macmillan 2000). Harlow himself, writing in 1868 while in contact with Gage's mother, somehow mistakes the year of Gage's death as 1861, whereas Macmillan shows conclusively Macmillan (2000), p.108. As discussed by Macmillan, Harlow's error in the date of Gage's death means that certain other dates given by Harlow for events late in Gage's life (such as Gage's move from Chile to San Francisco) must also be mistaken. This article follows Macmillan's corrections to these dates. that Gage actually died in 1860 — a striking if relatively unimportant illustration of the difficulty of establishing even basic fact about the case. In another example, several sourcese.g. H. Damasio (1994); A.R. Damasio (2005); Hockenbury D.H. and S.E. Hockenbury (1997) Psychology. state matter-of-factly that Gage's iron had been buried with him, but in fact Harlow's account of how he obtained the iron and the skull does not say this.Harlow (1868), p.342 More substantively, Macmillan points outMacmillan (2000), p.107 that in a passage which has been interpreted Damasio (2005). to suggest that Gage could not hold a job after his accident— ...continued to work in various places;' could not do much, changing often, 'and always finding something that did not suit him in every place he tried —Harlow is referring not to Gage's post-accident life in general, but only to the months between the onset of his convulsions and his death. Beyond the obvious importance of correcting the record of a much-cited case, Macmillan claims that "Phineas' story is worth remembering because it illustrates how easily a small stock of facts becomes transformed into popular and scientific myth," the paucity of evidence having allowed "the fitting of almost any theory to the small number of facts we have." Macmillan (2000), p.290; Macmillan (2008), p.831. A similar concern was expressed as far back as 1877, when British neurologist David Ferrier, writing to America for information in an effort "to have this case definitely settled," complained that "In investigating reports on diseases and injuries of the brain, I am constantly amazed at the inexactitude and distortion to which they are subject by men who have some pet theory to support. The facts suffer so frightfully...." Ferrier, D. (1877–79) Correspondence with Henry Pickering Bowditch. Countway Library (Harvard University) Mss., H MS c 5.2 (reprinted in Macmillan 2000, pp.464–5). Thus in the 19th-century controversy over whether or not the various mental functions are localized in specific regions of the brain, both sides found ways to cite Gage in support of their theories. Phrenologists made use of Gage as well, claiming that his mental changes resulted from destruction of his "Organ of Veneration" and/or the adjacent "Organ of Benevolence." It is often said For example, See additional discussion at Macmillan (2000), p.246. that what happened to Gage played a part in the later development of various forms of psychosurgery, particularly frontal lobotomy. Aside from the question of why the very unpleasant changes usually attributed to Gage would inspire surgical imitation, careful inquiry turns up no such link, according to Macmillan: }} Current research and daguerreotype portrait By late 2008 an advertisement for a previously unknown public appearance by Gage had been discovered, as well as a report of his physical and mental condition during his time in Chile, a description of what may well have been his daily work routine there as a long-distance coach driver, and more recently an ad for a second public appearance. This new information suggests that the seriously maladapted Gage described by Harlow may have existed for only a limited time after the accident—that Phineas eventually "figured out how to live" despite his injury, Fleischman (2002) and was in later life far more functional, and socially far better adapted, than has been thought.Macmillan (2008), p.831 Macmillan hypothesizes that this change represents a "social recovery" undergone by Gage over time, citing persons with similar injuries for whom "someone or something gave enough structure to their lives for them to relearn lost social and personal skills" (in Gage's case, his highly structured employment in Chile). If this is so then along with theoretical implications, it "would add to current evidence that rehabilitation can be effective even in difficult and long-standing cases," according to Macmillan, asking that, if Phineas could achieve such improvement without medical supervision, "what are the limits for those in formal rehabilitation programs?" In 2009 a daguerreotype portrait of Gage (above) was identified—the only likeness of him known other than a life mask taken around 1850 (above). It shows "a disfigured yet still-handsome" Gage Twomey (2010) with one eye closed and scars clearly visible, "well dressed and confident, even proud". He is shown holding the "iron" which had injured him, on which parts of the inscription (recited above) can be made out. (For decades the daguerreotype's owners had imagined that it showed an injured whaler with his harpoon.) Authenticity was confirmed in several ways, including photo-overlaying the inscription visible in the portrait against that on the actual tamping iron in Harvard's Warren Anatomical Museum; and similarly, matching the injuries seen in the portrait's subject against injuries preserved in the life mask. Macmillan cites the daguerreotype as consistent with the "social recovery" hypothesis already described. To better understand the question, he and collaborators are actively seeking additional evidence on Gage's life and behavior, and describe certain kinds of historical material (listed here) for which they hope readers will remain alert, such as letters or diaries by physicians who their research indicates Gage may have met, or by persons in certain places Gage seems to have been. See also * Traumatic brain injury Notes References *For general audiences: **Macmillan, M. The Phineas Gage Information page, School of Psychology, Deakin University, Victoria, Australia, including *** ** (Aimed at middle-school students) ** ** (Appendices reproduce Harlow 1848 and 1868, Bigelow 1850, and other primary documents, some unavailable elsewhere.) *** Paperback edition, 2002. ISBN 0-262-63259-4 *** See also Macmillan, [http://www.deakin.edu.au/hmnbs/psychology/gagepage/PgBook.php Corrections to An Odd Kind of Fame] *** Review: ** *Specialized reading: ** Barker, F.G. II (1995) Phineas Among the phrenologists: the American crowbar case and nineteenth-century theories of cerebral localization. J. Neurosurg 82:672–682 ** Bigelow, Henry Jacob (1850). Dr. Harlow's case of Recovery from the passage of an Iron Bar through the Head. American Journal of the Medical Sciences 20: 13–22 (Republished in Macmillan 2000). ** (First edition: 1994) ** ** Harlow, John Martyn (1848). "Passage of an iron rod through the head". Boston Medical and Surgical Journal 39: 389–393 (Republished in Journal of Neuropsychiatry and Clinical Neuroscience 11, 281–283; and in Macmillan 2000). ** Harlow, J.M. (1849). Letter in "Medical Miscellany." Boston Medical and Surgical Journal 39: 506–7 (Republished in Macmillan 2000). ** Harlow, J.M. (1868). "Recovery from the Passage of an Iron Bar through the Head." Publications of the Massachusetts Medical Society 2: 327–347 (Republished in Macmillan 2000). ** See also video reconstruction of tamping iron passing through Gage's skull in Further reading * * External links * Lists research questions related to Gage in localities throughout the US and Chile, for which Gage researchers request assistance from the general public. * Meet Phineas Gage — the story of how the daguerreotype's owners realized it depicted Gage. * Phineas Gage roadside memorial, Cavendish, Vermont Category:History of neuroscience Category:People with severe brain damage